Update – Cognitive Dissonance and Working with Trans Identified Teens

Thank you to my subscribers for reading my articles, I’m sorry I don’t post often; I’ve been working for a while now so have less time to write.  I work with teenagers so the topic of gender is relevant but I’ve found it’s not a big issue in my current team.   As a team we work quite individually and don’t have shared case reflections, so although I know there are a few trans identifying teens out of the 50-60 children we work with as a team I  have only worked with two young people with a trans identity and think as a team we have only worked with another 2 in the last year.  Consistent with the evidence coming out globally one was a young person with a history of trauma, neglect, poor parental boundaries in childhood (exposure to adult drug use and domestic violence at the very least) and possible sexual abuse in childhood, some of their family members also raised their thoughts that this young person may have autism.  They were same sex attracted and made it clear to me that they couldn’t imagine being a man with another man, which could suggest a binary/black and white view of sexuality consistent with being on the autistic spectrum.  They also spoke to me about being encouraged by their Mum to present In a feminine way and their main bonding activity was shopping together.

I worked with this young person in the same way I would any other; getting to know them as an individual and focusing on their immediate needs.  My work with them was very brief (less than 2 months) as they were on the cusp of adulthood, and they actually desisted in their trans identity during that period.  They had been identifying as trans for around 2 years having legally changed their name to an opposite sex one at age 16, he said he had made his own mind up about desisting and had applied to change his name back by deed poll before telling anyone.     

My feeling is that he butted up against the reality of bureaucracy; the process of getting a passport in a female name would involve more than a passport renewal in his birth name and sex.  He did appear more relaxed once he desisted, a socially anxious young man who would spend hours doing hair and make-up when trans identified was dressing casually and walking taller.  Still softly spoken and very slim he said he did miss the attention he got when dressed as a woman.  

I worked with another nearly 18 year old trans-identified teen, a flamboyant same sex attracted boy.   I worry about his future.  I worry about my own professional integrity; I know that there is a rising number of de-transitioners who did not find transition helped relieve their gender dysphoria  and that the complication rates with so called ‘bottom surgery’ (removal of testicles and inversion of the penis into a simulacrum of a vagina) are high and can leave no sexual function, incontinence and fistulas (warning graphic images on this medical paper).  Although this paper reports that there is a high satisfaction rate following ‘bottom surgery’ there is evidence in a long term study that people who underwent sex reassignment surgery were 19 times more likely to die by suicide.

Again my time working with this young person was limited and I needed to build a working relationship with him.  I gently shared my worries with him about him undergoing any surgery in the future but he is sure that’s what he wants.   Adults have the right to make ‘unwise decisions’ but I worry that he will be too influenced by our current social climate where trans identities are celebrated and his own impulsivity will prevent him from taking on board the information he will need to make an informed decision.  Will he even be given the full facts by whichever clinician he sees?  If he chooses not to have ‘bottom surgery’ but does take cross set hormones this is also a worry as it increases risk of stroke, heart attack and DVT.

 In my case records and conversations at work I refer to him as she/her; it’s not hard with a feminine presenting teenager but I think I would have more cognitive dissonance with using female pronouns for an older adult male or one who was more masculine in appearance.   When I started working I found it difficult, it would grate on me when I heard Social Workers talking about young people using opposite sex pronouns in the office (when the person wasn’t present).  I worried that this signaled that they ‘buy into’ the belief in gender identity and that people can change sex, but now I do it too.  I know through brief conversations that we all acknowledge the reality of these children’s sex but we have to follow the policies of our local authority which are focused on affirmation and acceptance.  Not only that but we have to build relationships with these teenagers which means accepting them as they are and gently bringing in that professional curiosity about their whole life.  I don’t remember who said it, maybe it was on the Gender a Wider Lens podcast – “a person is not just a walking gender identity”; there is so much more to explore with the teens I work with.

Developmentally teens are going through a period of individuation and identity development; they pull away from parents and gravitate towards peers.  They are looking for their tribe; if they have found it in the LGBT+ community we need to tread very carefully as they may be led to believe that anyone who does not affirm that they are really the opposite sex (or in the case of non-binary identifying people, no sex) hates them and wishes them harm.  Interestingly neither of the 2 teens I worked with were part of a real life LGBT+ community but I don’t know if they were accessing anything on-line.

For me the hardest thing about this work is worrying that by going along with the young person’s self declared gender identity I am complicit in harm.  If my involvement was longer I would be able to build a stronger connection and do that gentle exploration around what need a person’s gender identity meets for them.  As it is I am reassured by this video by Sasha Ayed (teen therapist and Gender a Wider Lens podcaster) – a reminder that although 16 & 17 year olds are not legally adults they are in the process of individuating and have to experience things for themselves and make their own mistakes as part of their development.  This does not mean affirming and going along with a teen’s transgender identity without discussion, but accepting that they need to have some autonomy.  In England 16 and 17 year olds (and adults) are covered by the Mental Capacity Act and have the right to make unwise decisions.  Working with this cohort as a Social Worker means I have to respect the young person’s autonomy but I also have a duty of care towards them.  It is not so simple as saying “I do not believe people can change sex”, there is a balance I need to make between relationship building and gently raising what I know about the dangers of surgery or hormones. 

I think it is very telling that on Social Work News there is no mention of the Cass Review or its findings, there has been no policy update or mention of it in from senior management in the Local Authority I work in, no change to their policy of affirmation of gender identity of young people we work with.   When I started a year ago the statutory Equality & Diversity training included information that people should be allowed to use the toilets of the gender they identify as and should not be told to use disabled/unisex toilets; what about the impact of this on women, particularly those whose religion prohibits sharing these spaces with men? 

I am currently trying to build up the courage to request a policy update in light of the findings of the Cass review about the lack of evidence base for puberty blockers and medical transition but also of the potential harms of affirming a child’s gender.  I think Social Workers need clear evidence based guidance that goes beyond affirming and links to stages of child development as the way we respond to older teens would be different from the way we would respond to younger children.  Busy Social Workers may still not be aware of what has been happening as there is still silence from our profession on this subject. 

In England we have a building resource of SEEN (sex equality and equity network) groups, none for Social Workers yet but we do have one for Local Authority workers.  There has been success in court with Social Workers Rachel Meade and Lizzy Pitt both given compensation for discrimination by their employers for the expression of their belief that sex is immutable.  But both those cases involved lengthy, distressing and expensive legal processes; something no one wants to go through.   I also want to be able to focus on the teens I work with and building relationships with them rather than fighting off complaints or a court case so for now will continue to write anonymously as and when I have time.

There are many other writers speaking out about this, have a look at my substack for recommendations.  For a UK perspective I recommend Sarah Phillimore (barrister in family law), James Esses (former barrister and Child Line volunteer who was suspended from his psychotherapist training course for his gender critical views); he writes about the ideological capture of institutions.  And Malcolm Clark, science documentary maker. 

As my time for writing is limited my next post will probably be a list of documentaries, podcasts and other resources for busy social workers who want more information.  Podcasts are a great way of finding out more as we can listen in the car as we drive, or at home as we do housework.

My no 1 podcast recommendation is Gender A Wider Lens.  If you do nothing else listen to all the episodes; they are Stella O’Malley (psychotherapist) and Sasha Ayed (teen therapist).  They’ve been running the podcast for 4 years and interview many people about different aspects of gender; medical, personal, social, the history of medical transition.  They approach the subject with curiosity and compassion, are an excellent source of information and are available on most podcast platforms.